Event Notification Report for May 01, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/30/2024 - 05/01/2024
Agreement State
Event Number: 57101
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Rush-Presb.-St. Luke's Med Center
Region: 3
City: Chicago State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Bill Gott
Licensee: Rush-Presb.-St. Luke's Med Center
Region: 3
City: Chicago State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Bill Gott
Notification Date: 05/03/2024
Notification Time: 10:27 [ET]
Event Date: 05/01/2024
Event Time: 00:00 [CDT]
Last Update Date: 05/03/2024
Notification Time: 10:27 [ET]
Event Date: 05/01/2024
Event Time: 00:00 [CDT]
Last Update Date: 05/03/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was contacted on 5/2/24 to advise that a patient who was administered Y-90 TheraSpheres on 5/1/24 received an underdose of approximately 23.6 percent. Both the patient and the referring physician were notified. There is no anticipated adverse impact to the patient and retreatment will not be necessary. The root cause has yet to be identified, and Agency inspectors will perform a reactive inspection the week of 5/6/24. This report will be updated as additional information becomes available."
IL Event Number: IL240011
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
The following was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was contacted on 5/2/24 to advise that a patient who was administered Y-90 TheraSpheres on 5/1/24 received an underdose of approximately 23.6 percent. Both the patient and the referring physician were notified. There is no anticipated adverse impact to the patient and retreatment will not be necessary. The root cause has yet to be identified, and Agency inspectors will perform a reactive inspection the week of 5/6/24. This report will be updated as additional information becomes available."
IL Event Number: IL240011
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
Non-Agreement State
Event Number: 57099
Rep Org: Reliable Testing Services
Licensee: Reliable Testing Services
Region: 3
City: St Louis State: MO
County:
License #: 24-35592-01
Agreement: N
Docket:
NRC Notified By: Gage Volmert
HQ OPS Officer: Adam Koziol
Licensee: Reliable Testing Services
Region: 3
City: St Louis State: MO
County:
License #: 24-35592-01
Agreement: N
Docket:
NRC Notified By: Gage Volmert
HQ OPS Officer: Adam Koziol
Notification Date: 05/01/2024
Notification Time: 16:58 [ET]
Event Date: 05/01/2024
Event Time: 12:00 [CDT]
Last Update Date: 05/01/2024
Notification Time: 16:58 [ET]
Event Date: 05/01/2024
Event Time: 12:00 [CDT]
Last Update Date: 05/01/2024
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RADIOGRAPHY SOURCE DISCONNECT
The following is a summary of information provided by the licensee via telephone:
On May 1, 2024, while conducting radiography on a weld using a QSA D880 with a 90 curie iridium-192 source, the source became disconnected from the cable when attempting retrieval. Surveys showed the source was still in the collimator. The radiation safety officer (RSO) set up boundaries and contacted the manufacturer for guidance. After about three hours, the RSO was able to return the source to its shielded container in the radiography camera. Pocket dosimetry indicated that the RSO received a dose of 178 mrem and the assistant RSO received a dose of 12 mrem. Film badge dosimeters will be read to confirm the exposures.
The following is a summary of information provided by the licensee via telephone:
On May 1, 2024, while conducting radiography on a weld using a QSA D880 with a 90 curie iridium-192 source, the source became disconnected from the cable when attempting retrieval. Surveys showed the source was still in the collimator. The radiation safety officer (RSO) set up boundaries and contacted the manufacturer for guidance. After about three hours, the RSO was able to return the source to its shielded container in the radiography camera. Pocket dosimetry indicated that the RSO received a dose of 178 mrem and the assistant RSO received a dose of 12 mrem. Film badge dosimeters will be read to confirm the exposures.
Agreement State
Event Number: 57111
Rep Org: Texas Dept of State Health Services
Licensee: IRISNDT Inc
Region: 4
City: Corpus Christi State: TX
County:
License #: L-06435
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Adam Koziol
Licensee: IRISNDT Inc
Region: 4
City: Corpus Christi State: TX
County:
License #: L-06435
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Adam Koziol
Notification Date: 05/07/2024
Notification Time: 15:50 [ET]
Event Date: 05/01/2024
Event Time: 00:00 [CDT]
Last Update Date: 05/07/2024
Notification Time: 15:50 [ET]
Event Date: 05/01/2024
Event Time: 00:00 [CDT]
Last Update Date: 05/07/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
O'Keefe, Neil (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
O'Keefe, Neil (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK SOURCE
The following was received from the Texas Department of State Health Services (the Department) via email:
"On May 7, 2024, the Department was notified by the licensee that on May 1, 2024, one of its radiography crews was unable to fully retract a 82.92 curie iridium-192 source into a QSA 880D exposure device. The radiographers had cranked the source out to test a weld, but when they tried to retract the source back to the fully shielded position they could not. The radiographers immediately notified the licensee's site radiation safety officer (SRSO), set up new barriers, and warned other individuals in the area. After a licensee manager arrived at the location, it was determined that a bend in the guide tube was too sharp to allow the source to be retracted. Using a set of 6.5 foot tongs, the SRSO repositioned the guide tube, and a radiographer was able to return the source to the fully shielded position. No individual received an exposure that exceeded 100 millirem. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: 10104
Texas NMED Number: TX240014
The following was received from the Texas Department of State Health Services (the Department) via email:
"On May 7, 2024, the Department was notified by the licensee that on May 1, 2024, one of its radiography crews was unable to fully retract a 82.92 curie iridium-192 source into a QSA 880D exposure device. The radiographers had cranked the source out to test a weld, but when they tried to retract the source back to the fully shielded position they could not. The radiographers immediately notified the licensee's site radiation safety officer (SRSO), set up new barriers, and warned other individuals in the area. After a licensee manager arrived at the location, it was determined that a bend in the guide tube was too sharp to allow the source to be retracted. Using a set of 6.5 foot tongs, the SRSO repositioned the guide tube, and a radiographer was able to return the source to the fully shielded position. No individual received an exposure that exceeded 100 millirem. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: 10104
Texas NMED Number: TX240014